This address is in the United States: Yes/No (INDEPAYMENT cannot work with debts owed by non-us debtors)

Yes

No

Email addresses of the person or entity owing money (debtor)

List as many as known

Phone numbers of the person or enitity owing money (debtor)

List as many as known

If the debtor is an entity, names of the individuals addressing the debt for the entity or who are in some way responsible for the debt

If the debtor is an entity, the Employee ID (“EID”) of the debtor, if known

If the debtor is an entity, the name of the owner of the entity, if known

Text If the debtor is an individual, the social security number of the debtor, if known

Bank account information for the debtor, if known (can be found on an old check or wire transfer you may have received which would have a routing number and account number)

The work was performed for the debtor’s personal, family or household needs

Yes

No

The work was performed for the debtor’s business or commercial needs

Yes

No

The date that you commenced work, if known

The date that you commenced work, if known

MM

DD

YYYY

Full amount you were supposed to be paid for your work

$

The date that you stopped work

The date that you stopped work

MM

DD

YYYY

The last date the debtor made any payment (if no payment was ever made, leave blank)

The last date the debtor made any payment (if no payment was ever made, leave blank)

MM

DD

YYYY

Amount of the last payment (if no payment was ever made, leave blank)

$

Total amount that has been paid to date (if no payment was ever made, leave blank)

$

Amount unpaid/amount of debt principal

$

By what date should the amount of debt principal have been paid per agreement or ultimatum

By what date should the amount of debt principal have been paid per agreement or ultimatum

MM

DD

YYYY

Unpaid invoice numbers, amounts, and dates sent

Please be as specific as possible. This information will be shared with the debtor.

Do you have an agreement regarding the payment of late penalties?

Yes

No

If “yes” what is the late penalty?

If the answer to above was “yes” calculate the amount of late penalties owed on the outstanding principal to date:

$

Full amount owed by the debtor to date

$

Have you used a debt collector to collect this debt in the past? (attempts made by you or the creditor don’t count)

Yes

No

If yes, how many third party debt collectors have you used?

1

2

3

4

More

Have you sued to get paid?

Yes

No

If yes, how much is the judgment for?

$

If yes, who is the judgment against?

Indescore: Indepayment allows you to give commercial debtors (debtors who used your product or services for a business purpose, rather than a personal purpose) an “IndeScore,” on a scale of 1 to 10, which tells other creditors and potential creditors of your opinion of the credit worthiness of the debtor. If you assign an IndeScore, and the debt is paid, the debtor’s IndeScore increases by 5 points. If the debtor ignores the debt, then the IndeScore remains where it is. The IndeScore you provide will be averaged with other creditor’s IndeScores for the same debtor. On a scale of 1-10, with 1 being very risky and 10 being very reliable, what is your opinion of the debtor’s credit worthiness? (if you don't want to assign an IndeScore, select "No IndeScore Assigned")

Network Participants: Indepayment notifies debtors who owe commercial debts that the Account has been registered with Indepayment, and provides the debtor an option to pay. Consumer debts or and commercial debts for which the debtor is located in Alaska, Arizona, Delaware, Hawaii, Idaho, Indiana, Minnesota, Nebraska, Nevada, North Dakota, South Carolina, Tennessee, Utah, or Vermont are automatically transferred to Network Participants. For all other debts, Indepayment offers the option of sending the account to a reputable debt collector, known as a “Network Participant.” You may authorize us to send the account to a Network Participant. Doing so will increase the likelihood of collection, but will also incur additional fees upon collection because Network Participants take a portion of the amount collected as their fee. Once you elect to transfer a debt is transferred to a Network Participant, you must cease all other collection activity (other than through Indepayment).

Yes

No

WRITE DOWN OPTION: Indepayment and its Network Participants (if you allow us to send your debt to one) will make every effort to collect every dollar you are owed, indicated in line “AA.” However, if we are able to negotiate with the debtor we are more likely to obtain payment. You may, therefore, authorize us to “write down” the debt, meaning we accept less than the face value. Do you authorize Indepayment and its Network Participants to write down the debt to less than the amount indicated in line “AA?

Yes

No

If you are allowing a writedown, what is the minimum amount you would allow the debtor to pay?

$

Thanks for registering an debt for collection with Indepayment. If this is a commercial account, we will notify the debtor that we are collecting the account If this is a consumer debt or a commercial debt and the debtor is located in Alaska, Arizona, Delaware, Hawaii, Idaho, Indiana, Minnesota, Nebraska, Nevada, North Dakota, South Carolina, Tennessee, Utah, or Vermont, we will refer your account to one of our Network Participants for collection. The IndeScore you gave the debtor will be tallied. We will notify you if your account is eligible for charge-off. Feel free to drop a line anytime to get the status of our collection efforts. If you have any questions, please contact us customerservice@indepayment.com.